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THE INFANT AT 4 WEEKS FOLLOWING BIRTH

INFANT ASSESSMENT DATA BASE


Review prior assessments for identified risk factors.

Activity/Rest
Infant sleep pattern well-established

Circulation
Heart rate ranges from 80–150 bpm at rest, with average rate of 120 bpm.
BP obtained by using flush technique at wrist ranges from 48–90 mm Hg, with a mean of
67 mm Hg; at ankle, 38–56 mm Hg, with a mean of 61 mm Hg.

Ego Integrity
Regards faces, especially parents’ faces, intently; may demonstrate beginning of social smile

Elimination
Urine pale or straw-colored, with output of 6–10 wet diapers per day
Abdomen soft, nondistended with bowel sounds present
Individual bowel elimination pattern established, dependent on type of feeding

Food/Fluid
Makes comfort noises during feeding, or may make small, throaty noises
Feeding generally 5–8 times per 24-hr period
Height gain 2.5 cm (1 in) monthly for first 6 mo
Weight gain of 3–5 oz/wk for first 6 mo
Drooling absent until 2–3 mo of age, when salivary glands begin to function

Neurosensory
Beginning to differentiate cry in relation to pain, discomfort, or hunger; uses cry to signal needs; quiets when picked up.
Head circumference increases 1.5 cm (1 2 in) monthly for first 6 mo.
Fontanels palpable and soft; posterior fontanel closes at 6 wk of age.
Tears present, with tear glands beginning to function at 2–4 wk of age.
Primitive reflexes present with strong, bilaterally equal responses.
Doll’s eye and dance reflexes fading.
Crawling movements when prone.
Lifts head momentarily from bed while on abdomen, turns head from side to side when prone.
Demonstrates tonic neck reflex when supine.
Marked head lag when pulled from lying to sitting position (back is uniformly rounded); absence of head control in
sitting position.
Strong grasp reflex: Hand closes on contact with object.
Responds to environmental stimuli: Bright objects (which are best viewed 8–12 in from face), sound, and touch.

Pain/Discomfort
Continuation of pain and cramping associated with colic may be reported.

Respiration
Signs of aspiration (continued regurgitation associated with reverse peristalsis and immature or relaxed cardiac
sphincter)
Safety
Axillary temperature stable between 97.7°F–98.6°F (36.5°C–37.0°C)
Perineal area clean and free of rashes

DIAGNOSTIC STUDIES
Testing dependent on individual findings, risk factors.
Urine Specific Gravity: 1.008.

NURSING PRIORITIES
1. Promote infant’s growth and development.
2. Provide information appropriate to parents’ learning needs.
3. Enhance home environment to promote infant’s safety, stimulation, and rest.

DISCHARGE GOALS
1. Various indicators of growth and development show progression WNL.
2. Parent(s) understand individual needs of infant.
3. Parent(s) demonstrate proficiency in infant care activities.
4. Plan in place to meet ongoing health monitoring/wellness needs.

NURSING DIAGNOSIS: NUTRITION: altered, risk for less than body requirements
Risk Factors May Include: Failure to ingest/digest/absorb adequate calories; e.g., biologic
(insufficient intake, malabsorption, congenital problem, or neglect
[failure to thrive]) or psychological factors (emotional abuse)
Possibly Evidenced By: [Not applicable; presence of signs/symptoms establishes an actual
diagnosis]
DESIRED OUTCOMES/EVALUATION Display physical growth and weight gain
CRITERIA—NEONATE WILL: appropriate for age and developmental stage.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Measure infant’s height and weight, and compare Nutrients for infants are based on body weight.
with measurements at birth and at 1 wk of age. Most full-term, AGA infants regain birth weight
Review growth history. within 10–14 days following birth. Weight gain
should be 3–5 oz/wk for first 6 mo and may be as
much as 1 oz/day in bottle-fed infant. Gains of less
than 3–5 oz/wk may result in lifelong nutritional
risks with potentially negative effects on infant
development.
Assess infant for possible failure to thrive (FTT). A breastfed infant who continues to lose weight after
10 days of life does not regain the weight by 3 wk of
age, or gains weight at rate below 10th percentile
after 1 mo is probably an FTT infant and requires
prompt evaluation relative to issues of lactation and
infant capabilities. In the bottle-fed infant, formula
preparation and appropriateness (tolerance) are
evaluated. Finally, concerns regarding possible
neglect must be addressed. Timely intervention and
resolution may prevent permanent deficits.
Determine amount, type, and frequency of Infants require about 115 kcal/kg for first 6 mo of
oral intake over last 24 hr. life, or 54 kcal/lb. Fluid needs are approximately 530
ml/day. One-third of energy is used for growth.
Inadequate caloric and fluid intake results in
nutritional inadequacies and poor weight gains.
Note: Adequate protein intake is critically important
to provide brain growth during the hyperplasia and
hypertrophy phase in the first 6 mo of life.
Inadequate protein ingestion during this phase can
result in developmental delays.
Note status of fontanels, production of mucus, Inadequate fluid intake results in dehydration,
skin turgor, and number of wet diapers per day. manifested by depressed fontanels, reduced urine
output, poor skin turgor, and dryness of mucous
membranes. Note: Cases of hypernatremic
dehydration have been associated with use of cow’s
milk feedings.
Obtain 24-hr dietary recall in lactating mother. Illness, infection, or marginal diet may affect
Note presence of illness, infection, or dietary mother’s ability to nourish the infant adequately.
inadequacies. Provide dietary teaching, as Factual information may help correct myths/
appropriate, noting cultural/religious practices. faulty beliefs resulting in inadvertent or deliberate
Identify adequate sources of calcium and food restrictions. Supplementing diet with brewer’s
protein; suggest supplementing maternal diet yeast improves milk production significantly
with brewer’s yeast as appropriate. more than simply adding similar nutrients.
Evaluate lactating mother’ sleep and rest, noting Inadequate sleep, resulting in excess fatigue, is
excess fatigue, family demands, and work or most common cause of inadequate milk supply,
social commitments. Discuss individual needs especially during 1st mo, when milk supply is
and options to meet these needs. being established.
Evaluate effectiveness of let-down reflex in Smoking and psychological stress may inhibit let-
lacating mother. If mother smokes, suggest that down reflex. While abstinence is preferred, the
she refrain or light cigarette after infant is sucking reality is that cessation of smoking may not occur
vigorously, rather than prior to feeding. Assist and achievable goals, such as reduction in
mother in evaluating stressors and using creative frequency/number of cigarettes may still be
problem solving. beneficial.
Review techniques used in formula preparation Many infant nutritional inadequacies are related to
and storage. Confirm that parents follow overdilution of commercial formulas, which
instructions for making powdered or concentrated results in inadequate calories, nutrients, and FTT.
formulas. Discourage home preparations of Use of home-prepared evaporated milk formulas
evaporated milk formula. has been linked to problems associated with improper measurement
and bacterial contamination.
Encourage continued use of formula for first 12 mo Skim milk contains about half the number of
of life. Discourage substitution of skim or calories in breast or commercial formulas; may not
whole cow’s milk. meet the infant’s energy needs; and may cause
deficiencies in iron, vitamin C, and fatty acids. Use of
whole milk in the first 12 mo may place the infant at
risk for iron, vitamin C, and copper deficiencies.
Inspect infant for lesions; note swollen parotid May indicate poor nutritional state, affect oral
glands. intake.
Determine color, frequency, consistency, and Altered elimination pattern may suggest problem
odor of stool. with digestion and absorption. Foul-smelling stool
suggests parasitic infection. Diarrhea may reflect milk
intolerance or ingestion of cathartics in lactating
mother.
Auscultate bowel sounds; palpate abdomen. Note Abdominal distension and gas accumulation may
presence of loose stools, cramping, crying, reports be associated with ingestion of gas-producing
of vomiting, or chronic blood loss in GI tract. foods in lactating mother or with milk intolerance.
Immaturity of the intestinal tract increases
permeability to inadequately catabolized proteins,
which produces an allergic response or milk
intolerance in 1%–2% of infants.
Assess infant’s color, gestational age, and weight Iron stores are usually adequate until infant
at birth, and current weight gains. weight increases by 21/2 times. Pallor and inadequate
weight gain, however, may indicate anemia.
Auscultate apical pulse and count respirations Persistent tachycardia >160–200 bpm associated
as indicated. with increased respiratory rate suggests anemia.
Note excessive or forceful vomiting of nonbilious, May indicate hypertrophic pyloric stenosis,
possibly blood-tinged emesis; visible gastric waves especially if infant appears alert and hungry, fails
moving right to left across epigastrium; and to gain weight, and has a history of recurrent
palpable olive-shaped mass in epigastric region. vomiting.

Collaborative
Provide information as needed about prescribed Alternative formulas relieve symptoms associated
alternatives to milk, such as soy milk formulas or with cow’s milk intolerance.
hydrolyzed protein and amino acid mixtures.
Refer to social services or WIC program, as Additional assistance may be needed to meet
indicated. infant/maternal nutritional needs if financial resources are limited.
Instruct in addition to human milk fortifiers FTT infants who are breastfed may benefit from
(HMF), as indicated, to breast milk, which is having the mother bottlefeed breast milk
pumped and stored for feedings. supplemented with extra calories until the infant is
gaining weight appropriately on a consistent basis.
Note: The morning and evening feeding may be from
the breast in order to support the maternal
breastfeeding experience.
Refer parents to pediatric nurse for assistance with Surgical management or pyloromyotomy is the
surgical preparation and care if pyloric stenosis standard treatment for hypertrophic pyloric
is confirmed. stenosis; prognosis is excellent, and mortality is low.

NURSING DIAGNOSIS: NUTRITION: altered, risk for more than body requirements
Risk Factors May Include: Obesity in one or both parents, rapid transition across growth
percentiles in infant
Possibly Evidenced By: [Not applicable; presence of signs/symptoms establishes an actual
diagnosis]
DESIRED OUTCOMES/EVALUATION Identify and adopt appropriate infant feeding
CRITERIA—PARENT(S) WILL: practices.
Explain factors that promote excess weight gains and eating problems.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Assess measurement of infant’s weight/height Weight greater than the 85th percentile in relation
for age and sex. Determine anthropometric to height, age, sex, and body build is considered
assessment. obese. Although anthropometric assessment is most
accurate, serial weight and height measurements in
relation to age are fairly good predictors of obesity or
excess weight gain.
Review parental weight history. Heredity and family feeding practices contribute to
obesity. There is an 80% probability that if parents
are obese, the child will also be obese. If parents are
not obese, this probability is only 7%.
Note type of infant feeding (i.e., breast or bottle). Breastfed infants are less likely to be obese than
bottlefed infants, because the breastfed infant
regulates the feeding based on hunger needs. In a
desire to empty the bottle, parents may overfeed the
bottle-fed infant by continuing to feed even after
satiation has been reached.
Determine amount and frequency of infant Feedings in excess of infant caloric needs relative to
feedings. energy expenditures result in excess weight gains,
possibly leading to obesity.
Provide information about infant’s energy Reduces likelihood of overeating.
requirements; encourage mother to let infant
regulate intake based on hunger needs.
Encourage mother to avoid introduction of solid Early addition of solid foods contributes to
foods until infant is at least 4–6 mo of age. development of poor eating habits, excess food
consumption, and infantile obesity. Mother may
mistakenly think that addition of solids enhances
infant’s chances of sleeping through the night, but
such practices have been found to have no effect on
infant sleep patterns.
Encourage mother to restrict the use of infant seat Enhances activity and energy expenditure.
during waking hours and to allow infant to spend
time on mat on floor.
Discuss mother’s feeding of infant for emotional Inappropriate use of food in response to
upsets or distress signals. newborn’s distress encourages infant to associate
food with emotional gratification rather than with
hunger.
Discourage substitution of skim or whole milk for Such substitution may increase renal solute load as
commercially prepared formula for first 12 mo a result of excess protein and mineral ingestion. Use
of life. of whole milk may result in increased plasma
osmolality, hyperphosphatemia, and hypernatremia.
Discuss possible lifelong risks associated with Overeating increases risk of health problems
overeating. related to cardiovascular system, hypertension, and
diabetes.
Review family eating patterns. Healthy eating habits and selection of appropriate
amounts and types of foods can ultimately affect
nutrition of the growing child.

NURSING DIAGNOSIS: KNOWLEDGE deficit [Learning Need], regarding infant care


May Be Related To: Lack of exposure/recall, misinterpretation, unfamiliarity with
resources
Possibly Evidenced By: Verbalization of problem/concern or misconcep-tions, inaccurate
follow-through of instructions, development of preventable
complications
DESIRED OUTCOMES/EVALUATION Provide appropriate nutritional intake.
CRITERIA—PARENT(S) WILL: Create safe, stimulating/restful infant environment.
Identify signs/symptoms requiring medical follow-up.
Use healthcare system appropriately.
Plan for short- and long-term child care.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Reinforce or provide appropriate information Helps ensure normal growth patterns in height
about infant’s nutritional needs for next few and weight, and may prevent overfeeding through
months. too early introduction of solid foods.

Provide information about role of iron in body and American Academy of Pediatrics recommends 1
the need for supplementation. mg of iron per kg of body weight per day for full-
term infants, starting no later than 4 mo of age. Iron-
fortified commercial formula for bottle-fed infant
offers most constant and predictable iron ingestion.
By 4–6 mo of age, breastfed infant should have
supplemental iron in form of iron-fortified cereal or
oral iron drops.
Discuss role of fluoride in body and in tooth Fluoride helps reduce incidence of tooth decay and
development. Encourage parents to obtain improves quality of tooth enamel, making it more
fluoride supplements if appropriate. resistant to caries, if fluoride is ingested before
eruption of teeth. Breastfed infants consume little or
no water and should receive 0.25 mg of fluoride per
24 hr for 1st yr of life. Although commercial formulas
have minimal amounts of fluoride, supplementation
is not necessary if home/bottled water supply used
in formula preparation contains 0.3 parts per million
(ppm) fluoride.

Review information for lactating mother, as The “reward period” for the breastfeeding mother
needed, including increased infant appetite and may not occur until 6 wk after delivery, and
caloric needs during growth spurts at about 6 wk she may need further encouragement and
and 3 mo of age. information to continue. Note: Infant may need to
nurse more frequently during periods of rapid
growth.

Determine how long mother plans to breast-feed. Anticipatory guidance related to the individual
Discuss techniques of weaning from breast when situation provides for anticipatory problem
desired and the process of introducing solids solving and enhances optimal outcome.
between 4 and 6 mo of age. (Refer to NDs:
Nutrition: altered, risk for less than body
requirements; Nutrition: altered, risk for more
than body requirements.)

Review signs of milk sensitivities, especially if If milk sensitivity is present, infant may require
lactating mother plans to wean infant to a bottle use of soy or other formulas. (Refer to ND:
when she returns to work. Nutrition: altered, risk for less than body
requirements.)

Discuss mother’s plans for possible return to work Allows mother to anticipate and plan for problems
and plans for child care and feeding practices. that may arise. Breastfeeding can be continued
Provide anticipatory guidance for lactating with adequate planning and management. Note:
mother to allow her to continue with Some employers have an area where
breastfeeding and to maintain milk supply. breastfeeding/breast pumping can be done.

Identify factors to be considered and resources Placing infant in care of others can be difficult for
available when choosing child care. Stress parents relative to issues of trust and child well-
importance of ongoing monitoring of care being. Informed choice and vigilance enhance
provided. parent(s) level of comfort and promote optimal
outcomes.

Provide oral or written anticipatory guidance Helps parent(s) to recognize potential safety
related to infant safety, including discussion of hazards and reduce risk of injury. Crawling reflex
potential accidental injury caused by suffocation, (which propels infant forward), rolling over,
falls, burns, motor vehicle accidents, or bodily increasing eye-hand coordination, and voluntary
trauma. (Refer to NDs: Suffocation/Trauma, grasp reflex increase risk of accidents in first 4 mo of
risk for.) life.

Provide information about importance of Immunizations begin in infancy to reduce


recommended primary schedule for immunization. incidence of infectious disease (diphtheria, tetanus,
pertussis, polio, measles, mumps, rubella, and
hepatitis B). Although recommendations are to begin
immunizations at 2 mo of age, current discussion
varies as to whether immunizations should begin at
birth or after the 1st yr to avoid possible untoward
responses.
Discuss timing and importance of infant’s regularly Helps detect any deviations from normal growth
scheduled well-baby visits to physician or nurse and development and ensure early intervention if
practitioner. deviations are identified.

Discuss infant’s physical, emotional, and Allows parents to monitor infant’s growth and
developmental needs. Provide oral or written/ development during infancy. May help reduce
pictorial information about anticipated monthly parental anxiety relative to individual infant
progression of physical (gross and fine motor) variations.
development, sensory development, and
vocalization and socialization.

Evaluate environment for its ability to provide Helps parents recognize the balance between
appropriate infant stimulation and rest. Assist play and rest and to provide optimal
parents as needed in planning for and providing environment for infant play, rest, and development.
appropriate visual, auditory, tactile, and kinetic At 1 mo of age, placing bright hanging objects
stimulation as well as quiet ideas for sleep. 8–12 inches from infant’s face or looking at infant
Discuss changing needs of infant play as from close range provides visual stimulation. Talking
development progresses during the 1st yr. to or singing to infant, or playing music box or
(Refer to ND: Sensory/Perceptual alterations, radio, provides auditory stimulation. Holding,
risk for.) cuddling, and providing warmth offer tactile
stimulation. Rocking infant in chair or cradle and
using carriage provide kinetic stimulation.

Review infant’s sleep-wake patterns. Suggest ways Rest periods/naps, usually after meals, are essential
to promote sleep through provision of warm, for continued growth. Intervals of sleep at night
nonstimulating environment, position changes, range from 4–10 hr with frequent naps and
and sleeping arrangements separate from increased periods of wakefulness without crying.
parents’ room. By 3 mo of age most infants have developed a
nocturnal pattern.

Reassess parent-infant interaction. Discuss methods Ongoing quality of emotional care is an important
to foster mutually satisfying interactions and aspect in promoting optimal infant growth and
development of infant’s trust. development. Mutually satisfying parent-infant
relationship fosters development of a sense of trust in
newborn.

Encourage parents to pay attention to infant cues Allowing infant to feel physically comfortable,
and to provide gratification soon after need warm, emotionally loved, and secure aids in
is identified. development of mutual trust and fosters
development of healthy ego in the infant. Delayed
gratification and/or meeting needs before infant
signals them can lead to development of a sense
of mistrust.
Offer anticipatory guidance, as appropriate, During 1st yr of infant’s life, both new and
regarding teething, shoes, use of pacifiers, experienced parents may have concerns or
thumb sucking, and so forth. questions, which if addressed early can foster
positive coping, reduce anxiety, and increase
problem-solving skills.

NURSING DIAGNOSIS: INFECTION, risk for


Risk Factors May Include: Immature immunologic response, increased environmental exposure
Possibly Evidenced By: [Not applicable; presence of signs/symptoms establishes an actual
diagnosis]
DESIRED OUTCOMES/EVALUATION Be free of infection.
CRITERIA—NEONATE WILL:
PARENT(S) WILL: Identify individual risk factors and appropriate interventions.
List signs requiring medical intervention.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Discuss newborn development and individual By 4 wk of age, the infant is usually out in public
risk factors. more often or may even be cared for outside the
home. The infant is particularly susceptible to coryza,
or the common cold, which is most frequently caused
by a rhinovirus and an immature immunologic
response. Because the infant has been an obligatory
nose breather and is only beginning to learn to open
the mouth in response to an increase in mucus
production and edema of nasal mucosa, respiratory
problems and an increase in airway resistance may
result. Possible complications such as otitis media,
sinusitis, or lower respiratory tract infection may also
develop.
Review signs of upper respiratory infection Reinforces parental learning to assist them in
(e.g., poor feeding, breathing difficulty, cough, identification of infant’s respiratory problems.
and nasal congestion) with parents.
Suggest elevating infant’s head/shoulders by Increases vertical chest capacity and lung
raising crib mattress to 30-degree angle when expansion with descent of diaphragm. Facilitates
infant has trouble breathing. drainage of mucus into stomach.
Recommend observing stool for passage of mucus. Because infant cannot blow nose, excess mucus is
excreted through the GI tract with the stool.
Observe parent(s) technique for using bulb suction Bulb suctioning of mouth first, then nose second
to clear mouth/nose of excess mucus. avoids introduction of microorganisms colonized in
nose into oral cavity/pharynx.
Review proper handling/cleaning of syringe. Bulb should be cleaned with hot water and allowed
to dry after each use.
Encourage giving infant sterile warm water Promotes hydration to help liquefy secretions.
between regular feedings twice a day, as appropriate.
Provide information about benefits of humidified Liquefies secretions and provides moisture for
air. mucous membranes, reducing risk of excessive
dryness/cracking.
Show parents how to inspect pharynx and to Enlarged lymphoidal tissue and appearance of
distinguish between viral and bacterial causative erythema (suggesting viral cause) or white exudate
agent if area is reddened or inflamed. Discuss (indicating bacterial or streptococcal cause) charac-
appropriate response. terize pharyngitis and tonsillitis. Viral infections may
resolve with only palliative measures, whereas
bacterial infections usually require medication.
Review methods for monitoring temperature. Digital pacifier or rectal are both acceptable techniques
for obtaining infant’s temperature with rectal result
approximately 0.5°F (0.28°C) higher. Note: Some
healthcare providers prefer rectal measurements.
Discuss signs indicating a deterioration in Involvement of lower respiratory structures or
newborn’s status and necessitating evaluation respiratory compromise requires further
by healthcare provider, such as pulling at ear evaluation and treatment. Infant is prone to
(as child gets older), croupy cough, elevated development of otitis media because of short,
temperature, cyanosis, and wheezing. distensible eustachian tubes, which open
inappropriately; an immature humoral defense
system; and pooling of fluid in pharyngeal cavity
when infant is in recumbent position.
Instruct parents not to medicate infant without Information about administration of medications,
discussing such action with healthcare provider. when to use them and when not to use them, helps
parents know when to ask for assistance.
Demonstrate medication administration Enables parents to provide optimal care for
(e.g., antibiotics, ear or nose drops). infant’s individual needs. For example, saline nose
drops instilled 15 min before feedings may improve
oral intake at mealtime. Note: Use of nose drops in
newborn is somewhat controversial, because drops
may lead to aspiration if they are improperly
administered.

Collaborative
Provide referral for laboratory studies (e.g., Helps confirm infectious process and identify
complete blood count with differential [CBCD], pathogens, especially when causative organism
throat culture) if needed. may be beta-hemolytic streptococci.

NURSING DIAGNOSIS: SUFFOCATION/TRAUMA, risk for


Risk Factors May Include: Lack of ability to protect self (infant), lack of awareness of hazards
(caregivers)
Possibly Evidenced By: [Not applicable; presence of signs/symptoms establishes an actual
diagnosis]
DESIRED OUTCOMES/EVALUATION Be free of injury.
CRITERIA—NEONATE WILL:
PARENT(S) WILL: Institute appropriate environmental adaptations or precautions to
prevent accidental injury.
Demonstrate concern for infant’s well-being by responding to crying
with soothing techniques, reacting appropriately during interactions
with infant, and raising appropriate questions and concerns.
ACTIONS/INTERVENTIONS RATIONALE

Independent
Provide oral or written/pictorial information Allows parents to focus on age-appropriate safety
about infant’s motor development between measures. The major developmental changes that
1 and 4 mo of age, its effect on mobility, and the occur between birth and 4 mo of age are increased
increased risk of injury. eye-hand coordination, development of voluntary
grasp, ability to roll over, and increased possibility of
movement associated with crawling and with Moro’s
reflex.
Review environmental factors that place infant at Improper storage and use of plastic bags, loose-
risk for suffocation. fitting sheets or soft mattress/pillows, opportunities
for drowning, and strings around pacifiers/bibs
(especially if they are worn at nap time or at night)
place infant at risk for suffocation.
Discuss dangers associated with aspiration and Aspiration dangers at 1 mo are most often related
proper use and storage of baby powder. to baby powder container, which because of its shape
may be held like a bottle, thereby creating risk of
inhalation, aspiration, and possibly fatal asphyxiation.
Provide anticipatory guidance regarding necessity Regurgitation associated with reverse peristalsis
of burping infant before placing in bed, proper and immature or relaxed cardiac sphincter
positioning, keeping small objects out of infant’s increases risk of aspiration. As infant’s
reach, avoiding use of clothing with buttons, coordination and strength increase, potential exists
avoiding balloons or toys with removable parts. for infant’s pulling toys and decorations apart and
putting small pieces in mouth.
Reassess and discuss other home safety factors, Reminds parents of situations that may present
including precautions for home layout and danger for their infant; provides opportunity for
furniture used for infant care, cigarettes and problem-solving individual needs.
second-hand smoke, hot liquids, and motor
vehicles.
Reevaluate parents’ understanding and practices Keeping diaper pins closed and out of infant’s
related to the potential for bodily harm to infant. reach and carefully putting away scissors, knives,
Provide information as needed. and razors reduce risks associated with bodily injury
from sharp or jagged-edged objects as infant matures
and becomes more active.
Assess emotional tone and quality of parent-infant Failure of parent to have fun, talk, and make eye
interaction. Note response to infant’s crying and contact with infant; anger or frustration in
nature of adjectives used to describe infant. response to crying episodes; and repeated use of
negative adjectives to describe infant indicate a
negative emotional bond with infant, which may lead
to emotional or physical abuse.
Evaluate infant for physical evidence of abuse. Excessive bruising, pinch marks, handprints, lacera-
tions, abrasions, malnutrition, FTT, or lack of subcu-
taneous fat indicates possible child abuse/neglect.

Collaborative
Make appropriate referrals to healthcare provider, May be necessary to help parents develop positive
community agencies, and support groups. parenting skills and reduce possibility of physical or
emotional harm to infant.
Report suspected abuse to physician and Suspected child abuse may warrant further
appropriate social or child-care agency. investigation before permanent injury or death
occurs. Note: Most states have statutory guidelines
requiring reporting of suspected child abuse/neglect.
NURSING DIAGNOSIS: PAIN [acute], risk for
Risk Factors May Include: Accumulation of gas in a confined space with cramping of intestinal
musculature
Possibly Evidenced By: [Not applicable; presence of signs/symptoms establishes an actual
diagnosis]
DESIRED OUTCOMES/EVALUATION Be free of, or display less frequent, crying spells
CRITERIA—NEONATE WILL: and episodes of colic.
PARENT(S) WILL: Identify/demonstrate appropriate techniques to relieve newborn
anxiety and tension.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Evaluate infant’s behavior. Helps differentiate cause of problem. For example,
colicky infant typically cries loudly, draws legs up to
abdomen in pain, clenches fists, and sucks
vigorously. Infant with otitis media may pull at
affected ear.
Determine what parents have done previously Assists in determining interventions that may be
and success of those interventions. helpful at this time.
Reassess diet of lactating mother and infant Helps identify specific foods or errors in feeding
feeding/formula preparation procedures. process that may be causing discomfort.
Discuss physical condition and infant’s well-being. Gastric acidity reduces within 1st wk of life, affecting
digestion and development of colic, which often
resolves within 2–3 mo. Despite colic attacks, infant
normally thrives, gains weight, and tolerates
feedings.
For additional interventions, refer to CP: One
Week Following Discharge; ND: Pain [acute],
risk for.

NURSING DIAGNOSIS: SENSORY/PERCEPTUAL, risk for alterations


Risk Factors May Include: Immature development of sensory organs, inappropriate/inadequate
environmental stimuli; effects of disease, trauma, drugs
Possibly Evidenced By: [Not applicable; presence of signs/symptoms establishes an actual
diagnosis.]
DESIRED OUTCOMES/EVALUATION Provide adequate/age-appropriate stimulation.
CRITERIA—PARENT(S) WILL:
Identify impairments.
Initiate appropriate interventions.
ACTIONS/INTERVENTIONS RATIONALE

Independent
Repeat the Brazelton Neonatal Assessment Scale Measures cerebral and neurological functioning
as appropriate, and compare with previous testing. and assesses interactive behavior. Although testing is
usually done at 3 days of age, prolonged effects of
intrapartal events/birth stress may affect initial
results. Reevaluation provides opportunity for
comparison and to verify appropriateness and
progression of responses.
Observe responses to visual, auditory, or tactile The adequacy of sensory modes (e.g., visual,
stimuli; note motor function and reflexes. auditory, and tactile) in a 4-wk-old infant is
determined by eliciting responses and evaluating the
age-specific response. Causes of deviations in sensory
perception may be related to vascular or traumatic
injury that develops over a period of hours; toxic,
infectious, or electrolyte imbalances that peak in
several days; or congenital or degenerative injuries
that develop or worsen insidiously over days, weeks,
and months.
Determine occurrence of recent illnesses of infant Helps detect environmental infection and illness;
or family members, prenatal or intrapartal may rule out mechanical causes of alteration.
complications and postnatal course.
Assess parents’ behaviors and responses to infant Helps identify possible inadequacies in parent-
using such measures as Cropley’s Critical infant interaction and establishes them as causative
Attachment Tasks, Maternal Tasks, Mother-Infant factors in infant’s unresponsiveness to
Screening Tool (MIST), and Reiser Fathering surroundings.
Assessment Tool.
Encourage parents to stroke infant gently from Stimulates sense of touch; conveys feelings of
head to toe with hand, washcloth, or cotton, and warmth and protection.
to hold, caress, cuddle, and swaddle infant.
Suggest parents place mobiles or bright, shiny Stimulates visual development. At 4 wk of age,
objects within 8–12 in of infant’s face, to look infant can see shadows and outlines, showing
at infant en face (face-to-face) at close range, and preference for circular shapes, intricate patterns,
to decrease intensity of light and move objects and human faces.
slowly.
Discuss placing ticking clock or radio playing soft Provides auditory stimulation and may be
music near infant, playing tape of parent reading soothing to infant; e.g., clock may stimulate
a story, talking or singing to infant, and playing human heartbeat.
music box.
Encourage parents to rock infant, place infant in Provides kinetic stimulation.
swing, gently cradle infant in arms, and take infant
for walks in carriage or in backpack placed close to
back or chest.
Assess strength of muscles, finger grasp, limb Provides parents with information about the
recoil, and stretching. Institute age-appropriate infant’s ability for reciprocal behavior. Specific
exercises. exercises stimulate sensory development.
Collaborative
Refer to other resources (e.g., physician, nurse May be necessary for follow-up care and
practitioner, physical therapy clinic, parenting evaluation of identified problems. (Provides role
classes and support groups) as indicated. models, facilitates role transition and skill
acquisition.)